Question/Concern About Coding in EHR


True Blue
Overland Park, KS
Best answers
I have a question for those of you who have experience with an EHR that I hope someone can chime in on, please.....the EHR that we currently use at our sites allow the physician or provider to perform their own coding. When diagnosing the patient, the provider actually has to select an ICD-9-CM code. The providers also select the appropriate CPT/HCPCS codes for any procedures performed. A superbill is then generated and this goes to the billing office for review before being submitted to any payer. If the billing office discovers a problem, they send the superbill back to the provider for correction.

Here is the providers are not coders. They are not trained to code and many of them have no basic concept of coding and when they receive these corrections back, they struggle with how to fix them because they don't understand coding and feel that the billing office should be taking care of this for them instead.

Here is the my question....if the billing office discovers the coding is incorrect, can they make the necessary changes to the superbill based on the documentation without the codes actually being changed in the note? For example, if the provider administered a flu vaccine and this is clearly documented in the note, but the provider selected the code for a pneumonia vaccine instead, can the billing office change the superbill to reflect the flu vaccine as is documented in the note, even though the code in the note shows a pneumonia vaccine? If we were audited, would this make difference if the superbill showed the coding that was clearly documented in the note, but the provider selected a different code in the note? I hope this question makes sense.
Documentation must match the claim. The superbill is neither part of the medical record, nor evidence that a service was performed.

Therefore, as long as an audit trail exists, showing who made the changes on the submitted claim, there should not be a problem. In the event of an audit, the health record (EHR) must clearly show a service was performed, regardless of whether or not the EHR "coded" it. Not all EHRs are created equally, so an auditor should recognize that and chock up any variance to better charge capture on the part of the billing/coding staff.

Hope this helps. If not, email me and we'll work on this.
The EHR that I previously worked with had a disclaimer on all the notes that said the codes were preliminary and may not match the billed codes after review (not exactly in those words, more in legalese). The notes were then reviewed for accuracy and the corrections if any were documented. The original notes were never changed, but the record clearly showed that after audit the codes were corrected if necessary.